Patients: Insist on being an equal and active partner in your care

It was the beginning of my third year of medical school. I had just started my first clinical rotation. My very first patient was Ray, a middle-aged man with pancreatitis.

I presented his case to the team. “What are Ranson’s criteria?” the attending physician asked.

My mind went blank. “Uh, I’m not sure,” I said.

“Next time, you’d better be sure,” the attending said. He turned to my colleague, who promptly gave the correct answer.

On that first day of medical training, I learned that “I don’t know” is not an acceptable answer. If you don’t know, look it up. Make it up you have to. Whatever you do, never admit that you don’t know.

Not surprisingly, doctors end up not tolerating uncertainty. In our high-tech era, this means more is done. A patient has seemingly vague symptoms, so the doctor orders some laboratory tests “just to get a baseline.” A doctor doesn’t know what’s causing the headache, so she orders a CT or MRI “just to see.” Medical students are rewarded for pursuing obscure diagnoses, so they order increasingly esoteric tests “just in case.”

This insidious practice has resulted in a culture of overtesting and overtreatment. Studies show that 30% of all medical care—at the tune of $700 million per year—is waste. Not only does this impose a heavy financial burden on society and on patients, it also results in avoidable harm. Every test has risks and potential side effects. A CT scan has a risk of radiation, for example, that may lead to cancer later in life. And one test often leads to another, even riskier, test.

Recently, my husband had an itchy rash on his arms. He mentioned this to a dermatologist friend, who recommended that he come into the office for a skin biopsy. I asked how the biopsy would change my husband’s management: regardless of what it showed, wouldn’t he still use a steroid cream? Sure, the dermatologist said, but at least we’d have more information.

Nothing against our well-intentioned friend, but this is a case where more information isn’t better. Why get a biopsy — an invasive procedure with risks including bleeding and infection — when it wouldn’t change the management or the outcome? Yet, tests are done all the time to quench the insatiable curiosity inherent in medicine: we just have to know.

Here’s another common scenario. A young woman comes in with abdominal pain. She’s able to eat and drink and looks well, but has a pain in her belly that’s bothering her. Many doctors would order a CT scan of her abdomen to make sure there’s not something bad going on. But what is this bad thing — how likely is it? How does the patient feel about the risks of the test, versus the risks of watchful waiting? If she’s fine waiting, then why expose this young person to unnecessary radiation, when it would be just as reasonable to wait to see if she gets better the next day?

More tests and better technologies are not the solution to improving clinical care. In fact, we know that 80% of diagnoses can be made without any tests at all, but by carefully listening to the patient’s story. I’m an emergency physician, yet even in the emergency setting, it is rare that a patient requires one particular test, and that test must be done right now.

Here’s what to do instead. Doctors: talk to your patients. If you’re not sure, tell them. Patients prefer honesty to false reassurance. Instead of reflexively ordering a test, discuss the benefit of the tincture of time. Remember that our first principle is to “Do no harm.” I just met two doctors, Tanner Caverly and Brandon Combs, who started an educational initiative to encourage doctors-in-training to write vignettes of medical overuse. To them, and to a growing number of physicians including the Lown Institute’s Right Care Alliance (of which I’m a proud member), preventing overuse is an ethical imperative.

Patients: insist on being an equal and active partner in your care. Ask why and how. Why is this test ordered? How will this test change my management? Make sure you know your diagnosis. Assure your doctor that it’s okay if she is not 100% sure; you don’t demand certainty, but you do expect transparency.

It’s taken me nearly ten years to unlearn the bravado I acquired in medical training and to learn that uncertainty isn’t bad; more isn’t always better; and less can be more. As the great cardiologist and humanist Dr. Bernard Lown says, you should always feel better after having gone to your doctor. We need to focus on healing by teaching and practicing the art of listening, compassion, and kindness.

Patients: Insist on being an equal and active partner in your care 17 comments

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Anthony D

Of course, I always ask my physician to be fair and balance to me!

meyati

That doesn’t always work. A good doctor can be overwhelmed, which leads to being unfair.

We have to trust them-what else can we do? I’m good at researching-but things come up where I’m like a child.

http://onhealthtech.blogspot.com Margalit Gur-Arie

First, I would recommend a little research to find out what “studies” suggest that $700 Billion (not million) per year is indeed waste (and what waste means in this context). Mr. Orszag waking up one morning and making a statement after he read a New Yorker article does not constitute a “study”.
Second, what is wrong with expecting students to master the materials? I don’t know is not an acceptable answer for any impromptu quiz or formal test in any discipline.
And by the way, I completely agree that you shouldn’t overtest your patients, but the reasoning has to be correct too.

guest

But when the point of a blog post is to establish a social media footprint, research is not really necessary…

Lynn Polizzi, LMSW

You left out a very very big part of this. The reason that these tests are being ordered like hamburgers at McDonalds is due to the current over-zealous and destructive torts laws that make everyone physician and their brother worry if they miss something, they will pay dearly. If we could get this under control, I guarantee you that this number would drop 10 percent. The overuse of tests when up concurrently with the increase in medical malpractice cases – that is the culprit here. TORT REFORM FIRST!

JPedersenB

You make very good points. I agree that tort reform would help rein in the malpractice madness. This needs to be addressed by our legislatures.

Another big problem and part of the malpractice problem is the relentless testing of healthy, aysmptomatic people “just to be sure.” If you refuse the tests, you will not find your doctor very happy and may get dropped from the practice….

meyati

That’s exactly why I took Simvastatin for preventive medicine. I was scared that I’d be dropped from the plan and left without a doctor. I thought if it didn’t work that I’d throw up or get depressed or something. I didn’t expect to have my legs muscles and tendons really messed up. For some reason, my doctor isn’t making any comments about how I’m slowly but surely becoming obese.

querywoman

GW Bush, as governor of Texas, helped implement a law forbidding HMO”s from taking punitive action against subscribers who complain about services.
Does your state have such a plan?

FriendlyJD

It’s too easy to cry “Tort reform!” and run away from issue Dr. Wen is discussing. Most medical malpractice cases don’t arise from doctors failing to order necessary tests; they arise out of testing errors or a failure to accurately interpret and follow-up on diagnostic tests. A physician following Dr. Wen’s reasoned approach is not inviting an automatic malpractice suit.

Leslie Kernisan, MD

Terrific post! May I suggest a variant on the question that patients might ask the doctor: “How do you expect the results of this test/procedure/approach to help me reach my health goals?”

Thanks for bring attention to this important issue

Not Kenwestmoreland

“In fact, we know that 80% of diagnoses can be made without any tests at all”

…she claims, linking to a 38-year-old article in the BMJ.

Some of us might be hoping that American medicine in 2013 is a little more advanced than 70s-era NHS standards.

meyati

I did a lot better in the 1970s than I’m doing now-my age has nothing to do with it-the doctor had a lot to do with it. I was poisoned by statins 2 years ago-it was preventive medicine strongly encouraged by the HMO. I’m getting ready to demand another round of physical therapy. I had to hire a dog walker. My family is asking if marijuana is given to people with back pain- why can’t I get some for severe leg pain? Sometimes I wake up barely able to stand because of my legs and Achilles tendons.
Until about 2000 I could get acetophenamin free codeine. I’m allergic to acetophenamin, so I seldom don’t get anything for pain- this includes being attacked by dogs, jamming my arm into the rotator cuff and not being able to move my arm, and having part of my nose and lip cut off because of cancer.

Also, you didn’t have to have a crystal ball to forecast strep throat a month ahead of time, so you could make an appointment.
My health goal is to try to get medical care and avoid more poisoning. I wish that I could add having PCP that actually had a dim idea of who I am, but I’m a realist.
Also- how about having somebody that’s responsible for something, anything?

kjindal

What about when patients or their families demand tests that aren’t indicated, despite lengthy discussions with their MD? Is that the primary care MD’s failure in “talking to the patient”? That is a typical ER doc oversimplification.

http://www.myheartsisters.org/ Carolyn Thomas

Couldn’t agree more, Dr. W. With the rush of many docs to “treat the numbers”, it’s easy to understand how the hands-on concepts taught by Dr. Lown and so many others for decades have been thrown under the high-tech bus. Thus, as reported in the NEJM, women under the age of 55 are seven times more likely to be misdiagnosed in mid-heart attack and sent home from the ER compared to our male counterparts because our “numbers” look “normal” – no matter what the actual symptoms are clearly telling the physician. I was one of them – misdiagnosed with GERD and sent home despite central chest pain, nausea and pain radiating down my left arm. Since my heart attack, I’ve encountered docs who barely made eye contact (or even touched me!) because they were busy checking my “numbers” while reading reports, test results and laptop screens. Just wait until our docs are all wearing Google Glass . . .

rbthe4th2

I agree! I’ve been NON treated by the numbers and keep getting sicker. They can’t figure out why although I’ve told them time and again what it is.

Sherene

Some patients would rather not have tests done but I’d say the majority do want the (noninvasive) tests to rule things out, for peace of mind, especially if they don’t think their doctor is truly paying attention to their symptoms. Sometimes they will see you not wanting to order tests as a way of your saving money, rather than really looking out for them.

For the record, I have never had a doctor order a CT scan when I or my kids have had abdominal pain. If anything, the doctor would start with an ultrasound, maybe some blood tests or a stool pathogen test (even that is a stretch). Luckily we’ve not had any horrible afflictions that would require further testing but certainly, the starting point has never been a CT scan. Also, I’ve never had a doc order a skin biopsy for an itchy rash. But I’ve also not been prescribed a steroid cream every time I or a family member has had such a rash. Sometimes if they don’t know the cause they have suggested leaving the rash alone and seeing if it goes away in time. Seems reasonable to me, as long as the doc explains her reasoning and – this is important – if you have to return, you don’t have to wait forever to see the doctor.

meyati

This is about a physician learning to trust his instincts, and has nothing to do with the patient. I have hypothyroid- a few years ago I had a doctor that wanted to treat the symptoms, not the cause-and this was even after I nagged her into do lab work for thyroid-and the lab stated that I was out of range for TSH, T3 and T4. I looked healthy-but I wasn’t.